THE SURVEY PROCESS Assisted Living Facilities and Specialty Care Assisted Living Facilities ALMDA Winter Meeting January 30, 2016 Assisted Living is a State only enterprise no federal regulations Two Basic Levels of Care: (Regular) Assisted Living Specialty Care Assisted Living for persons with cognitive dysfunction 1
The type of assisted living facility is based on the maximum number of beds = residents for which the facility is authorized to provide care 1. Family Assisted Living two or three residents 2. Group Assisted Living three to 16 residents 3. Congregate Assisted Living more than 16 residents The rules for (regular) Assisted Living Facilities were recently amended. Alabama now allows any individual to care for two unrelated persons in their own home without a license. THE RULES ALSO CHANGED THE DEFINITION OF A GROUP FACILITY TO ONE WITH 3 16 BEDS The rules were changed to eliminate the addition of any new Family Assisted Living Facilities (2 3 beds). The three currently licensed Family Assisted Living Facilities will be able to renew the license yearly. And they will be subject to surveys on a regular cycle; and enforcement action would be taken if failure to comply with the rules were to be found. 2
All applications for a new facility having only 3 beds (thus 1 3 residents) will be subject to the building, fire and safety codes for a GROUP facility (the same as the current 16 bed (1 16 resident) facilities. Any new application for a two bed facility will be denied on the grounds that no license is necessary. Assisted Living Statistics for Alabama Assisted Living Facilities: 209 with a total of 7,429 beds Specialty Care ALFs: 97 with a total of 2,720 beds Total facilities: 306 Classification of assisted Living facilities by size Regular ALF: Family: 3 9 beds Group: 96 1,497 beds Congregate: 110 5,923 beds Specialty Care ALF: Group: 53 Congregate: 44 905 beds 1,815 beds 3
Bureau Survey Staff: 8 total 1 Supervisor 1 Coordinator 6 Surveyors All Registered Nurses trained in the survey process for ALF and SCALF 3 stationed in Montgomery 2 stationed in Birmingham, Jefferson County 1 stationed in Mobile, Baldwin County All survey staff participate, to a varying degree of frequency, in the on site survey process. Additional responsibility of this unit of the bureau is that of investigation of unlicensed health care facilities in Alabama. Types of surveys Initial Routine also called a regular survey Investigation Follow up Complaint 4
Types of surveys Initial: Every new SCALF has a survey before the first resident is admitted. This comes after the building is inspected by the technical services section which approves the construction and fire and safety code compliance of the building. For every new ALF the policies and procedures are reviewed before the approval for licensure is given. An initial survey may be conducted at the discretion of the supervisor. Types of surveys Routine: This is to confirm basic compliance with the rules of the State Board of Health. Investigation: done in response to a self reported incident that triggers concern, & to verify the facility s response. Follow up: to confirm that corrections were made and compliance achieved. Complaint: to investigate allegations of rule violation(s) from a third party. Priority determination for surveys 1. Highest priority: Complaint survey: prioritized with most egregious taking priority over all other surveys. Occasional Investigational survey following an alarming incident report. 2. High Priority: Follow up: conducted during the probational period (time sensitive) Initial inspections primarily new SCALF 5
Priority determination for surveys 3. Medium Priority: Investigational triggered by a self report of an incident. Routine the Department s goal is to inspect every recently licensed ALF or SCALF facility within the first year to 18 months of operation [unless there is a reason (such as a complaint) to indicate the need for a survey prior to that]. Priority determination for surveys 4. Low priority Routine for an established facility. Determined by how long it has been since the previous routine survey or last survey of any type. Each survey normally consists of five steps: 1. Review of the last survey report, facility incident report statements, and any complaints pending investigation. 2. Actual on site inspection and collection of data the unannounced survey. 3. Write up of the findings the Statement of Deficiency (SOD) 4. Review, revision and distribution of the SOD. 5. Review and acceptance of the plan of correction or other administrative action. 6
Usual allocation of survey staff Family ALF one surveyor with the expectation of a one day (or less) survey. Single Group facility one surveyor with an expectation of one day for an ALF and possibly two days for a SCALF survey. Multiple Group facilities on the same campus One or two surveyors with the expectation of at lease two days for the survey. Congregate facility two to three surveyors with the expectation of at lease two days for the survey. Standard survey process 1. Entrance and tour of the facility 2. Meet with residents individually and ask general questions about care 3. Observations to determine care required and care provided 4. Observation of medication pass, MARs, medication storage and destruction 5. Observation of meals 6. Review of care plans, weight records and any special orders 7. Review of staff training and medical examinations. 8. Inspection of the kitchen Hierarchy of Deficiencies Health Related Issues Safety Related Issues Quality of Life The daily presence, in the facility, of a competent and caring Administrator and/or license holder/governing authority with the resident s best interests at heart is the best possible insurance against a bad survey. 7
Hierarchy of Deficiencies Health related issues 1. Actual harm to one or more residents 2. Potential for significant harm to resident(s) 3. Licensing, training and staffing of personnel 4. Accurate and complete records Actual Harm is nearly always a consequence of having ineligible residents who are inappropriate for assisted living. Potential Harm usually indicates failures to ensue fundamental and vital features of assisted living e.g. 1. having a trained attendant available at all times to help if needed; 2. having a mechanism of contacting the attendant; 3. having a plan for the caregivers to follow in providing assistance to each resident ineligible residents are at extreme risk for: 1. Weight loss. (This also encompasses): Failure to weigh residents Inaccurate weights recorded Falsifying resident weights 2. Multiple falls 3. Wandering and elopement of residents 4. Pressure wounds 5. Restraint use 8
Hierarchy of Deficiencies Safety related deficiencies 1. Yard and building maintenance 2. Kitchen and food preparation 3. Fire and disaster preparedness 4. Oxygen storage; and long O2 tubing creating a fall hazard Quality of Life Hierarchy of Deficiencies 1. Activity plan and implementation 2. Quality of food 3. Pest control 4. Cleanliness and freedom from odors 5. Deteriorating furniture; soiled furniture Our ten most frequently cited deficiencies 1. Failure to properly care plan: 420 5 4.05(3)(d)1 5 ALF 420 5 20.05(3)(d)1 5 SCALF 420 5 20.06(2)(d) SCALF 2. Failure to conduct and complete incident investigations: 420 5 4.05(3)(f)1 4. ALF 420 5 20.05(3)(f)1 4 SCALF 9
3. Admission/retention of ineligible residents: 420 5 4.06(2)(b) ALF 420 5 4.06(6)(a)(b)(c)(d)(e)(h) ALF 420 5 20.06(2)(g)(h)(j) SCALF 420 5 20.06(6)(b) SCALF 4. Failure to conduct appropriate resident assessments: 420 5 4.05(3)(d)1 ALF 420 5 4.06(2)(a) ALF 420 5 20.06(2) SCALF 420 5 20.06(6) SCALF 5. Failure to provide proper health supervision and assessment of residents: 420 5 4.06(2) ALF 420 5 20.06(2)(a e) SCALF 6. Failure to follow physician orders: 420 5 4.06(1) ALF 420 5 20.06(1) SCALF 7. Failure to follow all fire safety requirements: 420 5 4.11(1) 420 5 4.12(3)(o t) 420 5 20.11(1) 420 5 20.12(3)(o t) 8. Improper dish sanitization: 420 5 4.07(2)(a) 420 5 20.07(2)(a) 10
9. Staffing of the facility: 420 5 4.04(1) 420 5 20.04(1) 10. Training of staff: 420 5 4.04(4) 420 5 20.04(11) : what is available to the Department Alabama law does not provide for civil monetary penalties for violation of the rules. Administrative action is all that is available to the Department. Civil monetary penalties do arise for providing false information to a representative of the Department or discharging residents to an unlicensed health care facility. : what is available to the Department Administrative action is determined on a case by case basis for each facility. Circumstances may seem similar but each facility is unique. Decisions are made based on the best judgment of the Department as to whether or not there is a reasonable likelihood that the operator (or operators) of the assisted living facility (ALF or SCALF) is willing and capable of achieving and maintaining substantial compliance with the rules. 11
When there is blatant disregard for the health and safety of the residents, situations that clearly demonstrate global lack of oversight, no concern for the rules, with imminent danger to residents, the survey findings are presented to the Department s General Council and to the State Health Officer. After review he will issue an Emergency Order suspending the license of the facility and compelling the orderly discharge of all residents within 48 hours. Following such an emergency closure, a letter is sent by one of the Department s attorneys to the license holder with a date and time set for a license revocation hearing. The completed SOD accompanies this letter. The hearing is conducted by an outside attorney to give a ruling on the Department s demand that the license be revoked. The license holder and his/her legal counsel are invited to attend and may argue against revocation. For serious compliance failures when the Department judges that the operator is not willing and/or capable of achieving and maintaining substantial compliance with the rules, the Statement of Deficiencies is reviewed with our designated attorney from the Office of General Counsel (OGC). A letter is sent to the license holder informing them that a license revocation hearing has been set and explaining their rights under the Alabama Administrative Procedures Act (Code of Ala. 1975, Section 41 22 1 et. seq.). 12
For serious compliance failures when there is indication that the owner/operator is willing and capable of correcting all deficiencies, the Department reviews the Statement of Deficiencies with our designated attorney from the OGC. A letter is sent to the license holder asking that they meet with representatives from the Department to review the SOD and discuss licensure action. This often results in a settlement agreement. Occasionally the owner feels that she/he can no longer operate the facility and asks for specified time during which a sale can be completed. The most common response is for the owner to admit to poor oversight and significant mistakes; and to come with a list of changes already made or at least planned. The owner pledges to invest the time, the personal involvement and necessary resources to correct all failures. We enter into a written Consent Agreement that spells out what the operator must do to correct all deficiencies and provides a timeframe for achieving this. 13
When a Consent Agreement is concluded for serious deficiencies, the license is downgraded to Probational. A probational license is available as part of the enforcement action and temporary corrective measures to any individual or corporate license holder for any one facility only one time. If the follow up survey, done during the year long probationary period, demonstrated satisfactory correction of all deficiencies, the license is upgraded to Regular at the end of the probationary year. If the follow up survey does not document satisfactory compliance with the rules, a letter is sent with a date for a license revocation hearing. If that same facility with the same license holder / governing authority has a bad survey in subsequent years, the Department stipulates a license revocation hearing. For deficiencies that are not associated with actual harm, significant resident abuse and neglect, risk of potential significant harm, serious repeat deficiencies The Department requires a Plan of Correction that is acceptable for each deficiency. Each corrective action must represent a change in current behavior; designate a person to oversee the change; provide documentation of the corrective action; and a time frame for complete compliance. 14